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(BQ) Part 2 book Lasers in dermatological practice presentation of content: Sexually transmitted diseases, keratinising and papulosquamous disorders, connective tissue disorders, bullous disorders, sarcoidosis, amyloidosis, diseases of blood vessels and lymphatic system, diseases of pigmentation,...
Chapter Nonsurgical Tightening Simal Soin, Kabir Sardana Introduction Numerous attempts have been made at counteracting the signs of aging, such as redundant facial and neck skin In terms of skin laxity specifically, the gold standard of treatment remains rhytidectomy or surgical redraping However, with the recent advances in technology, conditions that once required major surgical intervention may not always require aggressive intervention Though nonablative lasers (long pulse 1,064 nm Nd:YAG), and fractional lasers have been used, radiofrequency (RF), infrared, and ultrasound devices are probably better, though the last is yet to find universal acceptance (Table 8.1) Radiofrequency energy works to tighten and lift tissue by delivering heat to dermal structures without adversely affecting the epidermis, thus making it an ideal choice for the nonsurgical face-lift This energy is produced by an electric current that does not diminish by tissue scattering or absorption by a chromophore Light-based treatments such as lasers and infrared devices rely on chromophores to produce antiaging effects Ultrasound waves induce molecules in deep tissue to vibrate, resulting in tissue heating Like RF energy, the ultrasound waves spare the epidermis Table 8.1 Overview of devices for skin tightening Device Skin tightening mechanism ThermaCool TC Monopolar RF Accent Bipolar RF and unipolar RF Refirme ST IR and bipolar RF Polaris WR Monopolar RF and diode laser (910 nm) Titan IR Lux-IR Fractional IR GentleYAG Long-pulse Nd:YAG USG Ulthera Nonsurgical Tightening 295 and cause selective heating of the deeper tissues We will focus on minimally invasive, nonablative tissue tightening techniques, including radiofrequency, light and ultrasound-based devices These devices are not a replacement for surgical procedures and appropriate patient selection remains key to overall satisfaction Radiofrequency Therapeutic use of RF technology was first introduced by Bovie and Gushing in the 1920s with the advent of electrocautery Since then, it has been used for a variety of medical purposes The discovery that this energy could penetrate deep into the dermis and fibrous septae that support underlying structures via the emission of high-frequency radio waves suggested that this technology could also be used to lift and tighten aging skin Apart from the three major subtypes, monopolar, bipolar and unipolar RF, some devices that are labeled to be tripolar or multipolar but are variations of the basic three forms of monopolar, bipolar, or unipolar (Table 8.2) Combination Devices Recently, devices combining RF and light systems were introduced in an attempt to treat both skin laxity and rhytides These include the ReFirme ST and the Polaris WR systems ReFirme ST combines broadband IR (700–2,000 nm) and bipolar RF energies (70–120 J/cm3), while the Polaris WR TM system (Syneron Medical Ltd, Israel) combines RF and 900 nm diode laser energies, known as electro-optical synergy or ELOSTM The optical energy component is used to selectively heat the target tissue Other energy sources, such as laser or intense pulsed light, can be combined with RF so that a large array of technologies use RF for the ultimate goal of smoothing and tightening of the skin (Table 8.2) Principles of RF It accomplishes its tissue tightening effects via a unique scheme that utilizes MRF energy at a wavelength of MHz The energy is applied to the skin via a handpiece that contains a single-use electrode tip A thin capacitive membrane located on the electrode couples RF to the skin by distributing RF energy (in the form of an electrical current) over a volume of tissue under the surface membrane A return electrode is placed at a distant site on the body, usually on the back, and an electromagnetic field is created that rapidly alternates from positive to negative charge As charged molecules pass through the electrical field, heat is generated by the resistance of dermal and subcutaneous tissues to the passage of the electric energy (Fig 8.1A) 296 Lasers in Dermatological Practice Table 8.2 Comprehensive classification of RF devices* Company and device Energy specifications Tips/ electrodes Comments Biorad GSD Tech Co, Shenzhen, China 1.15 MHz 1,000 W tips Continuous cooling; automatic resistance technology; single and continuous mode Cutera TruSculpt, Brisbane, CA MHz 4” handpiece Handpiece reads out once optimal temperature is reached of 43–45° C Ellman Pelleve, Oceanside, NY MHz small handpieces 7.5, 10, 15, 20 mm Several handpieces for smaller areas Can use unit as an electrocautery unit also RF + Cautery Thermage Solta Medical, Hayward, CA 6.78 MHz 400 W New handpiece (CPT: Comfortable Pulse Technology) with vibrations to improve patient comfort Pain nerval interceptors get confused and busy (vibrations, cooling, heating) Accent Family Alma Lasers, Caesarea, Israel 40.68 MHz Up to 300 W Unipolar+ bipolar+ fractionated RF Aluma Lumenis Ltd., Yokneam, Israel 40.68 MHZ Up to 300 W Bipolar and Unilarge handpieces Apollo-TriPollar Pollogen, Tel Aviv, Israel MHz 50 W handpieces Aurora SR Syneron/ Candela, San Jose, CA Up to 25 J/cm2 400–980 nm 580–980 nm 680–980 nm Elos Plus Syneron/ Candela, San Jose, CA 1–3 HZ Variable eMatrix Syneron/ Candela, San Jose, CA Up to 62 mJ/pin Monopolar Devices Bipolar RF FACES technology using functional aspiration RF + IPL RF + Infrared light Matrix of electrodes Fractional RF Disposable tip, which can prove to be a disadvantage over conventional fractional lasers Contd Nonsurgical Tightening 297 Contd Company and Device Energy specifications Tips/electrodes Comments EndyMEd PRO Deep Pole EndyMEd Medical, Caesarea, Israel MHZ 65 W handpieces Deep RF, Handpieces: Skin tightening, body contouring, facial tightening, fractional skin resurfacing Eprime Syneron/ Candela, San Jose, CA 460 kHZ 84 VRMS Microneedles 20 degree delivery angle, injected into dermis, fractional skin resurfacing eTwo Syneron/Candela, San Jose, CA 62 mJ sublative; 100 J/cm3 sublime Matrix of electrodes RF + IR Ray Life Ascepelion 0.5-1 mHz handpieces Suction and three modes Reaction Viora, Jersey City, NJ 0.8, 1.7, 2.45 MHz Body 50 W Face 20 W modes- 0.8, 1.7, 2.45 and multichannel SVC (suction, vacuum, cooling) devices TiteFx Invasix, Yokneam, Israel MHz 60 W VelaShape II Syneron/Candela, San Jose, CA Infrared- Up to 35 W RF Up to 60 W Velasmooth Syneron/Candela 700–2,000 nm Venus Concept-8 Circular Poles Venus Freeze, Toronto, ON RF: MHz Magnetic pulse: 15 Hz RF: up to 150-W Magnetic flux: 15 Gauss V-Touch Viora, Jersey City, NJ Bipolar w/suction real time epidermal temperature monitor Handpiece with bipolar Radiofrequency, Infrared laser, Suction Vsmooth (40 mm × 40 mm) and Vcontour (30 mm × 30 mm) treatment areas RF/Infrared light with mechanical manipulation Large hand piece poles mm apart, dual mode = bipolar magnetic field Multipolar RF and magnetic pulse hand piece-0.8,1.7, 2.45 SVC (suction, vacuum, cooling) devices handpiece Unipolar energy to heat fat, bipolar to deliver energy to dermis Non Contact Operator independent Unipolar RF Accent RF Alma Lasers, Caesarea, Israel 40.68 MHz Up to 200 W Multipolar Devices Vanquish BTL Aesthetics, Prague, CR *Please contact manufacturers for procedural details 298 Lasers in Dermatological Practice The device’s energy output is calculated using the following formula: Energy (J) = I2 × z × t where I is current, z is impedance, and t is time in seconds Energy (J) is created by the impedance ( z ) to electron movement relative to the amount of current ( I ) applied and the total time ( t ) that current is delivered to the tissue The heat generated is in the temperature range of 65–75°C, which can cause collagen damage, induction of an inflammatory response, thereby resulting in skin lifting and tightening (Fig 8.1B) Mode of Action Monopolar RF (Thermage) causes immediate skin tightening through collagen contraction since it heats the collagen in the dermis and fibrous septae in the subcutaneous fat layer The body interprets the heat as a wound and results in wound healing over a period of time The wound healing response results in clinical skin tightening Patients have improvement in Fig 8.1A: A diagrammatic overview of the mode of delivery of RF in ‘Thermage’ The electrical current passes through a single electrode in the handpiece to a grounding pad There is a high density of power close to the electrode’s surface with the potential for deep penetration of tissue heating Fig 8.1B: Illustration of the mechanism of collagen remodeling due to RF Nonsurgical Tightening 299 superficial laxity through collagen tightening in the dermis and subcutaneous laxity through tightening of the fibrous septae in the subcutaneous layer To denature collagen requires heating the tissue to a therapeutic temperature and then keeping it at that temperature The thermal effect causes the collagen to denaturize and this is transposed into a breaking of the intramolecular bonds Thus, the molecular structure of collagen is therefore shorter and thicker, which translates into a “tensor effect” that is visible and palpable (skin tightening) The thermal shock produces on the fibroblasts an increase in the production of physiological collagen It should be emphasized that this very heat can produce problems if too much heat is delivered as the collagen fibrils will denature completely above a critical heat threshold Conversely, if too little heat is delivered, there will be no tissue response, although it appears that mild thermal injury gives rise to new dermal ground substance and tissue remodeling of photodamaged skin over time The optimal shrinkage temperature of collagen has been cited as 57–61°C; however, contraction is in actuality determined by a combination of temperature and exposure time For every 5°C decrease in temperature, a tenfold increase in exposure time is needed to achieve an equivalent amount of collagen contraction The other main mechanism in skin rejuvenation is a secondary wound healing response that produces dermal remodeling over time The wound healing response entails activation of fibroblasts to increase deposition of type I collagen and encouraging collagen reorganization into parallel arrays of compact fibrils Variables that Affect RF Penetration With radiofrequency technologies, the depth of energy penetration depends on the configuration of the electrodes (i.e either monopolar or bipolar), type of tissue serving as the conduction medium (i.e fat, blood, skin), temperature, and the frequency of the electrical current applied Tissue is made up of multiple layers, which have different resistances to the movement of radiofrequency energy with the dermal tissue with higher impedance being more susceptible to heating As a thumb rule fat, bone, and dry skin tend to have low conductivities, thus the current tends to flow around these structures rather than through them Wet skin has a higher electrical conductivity allowing greater penetration of current This is the reason why improved results are seen with generous amounts of coupling fluid and increased hydration of skin The structure of each individual’s tissue (dermal thickness, fat thickness, fibrous septae, number and size of adnexal structures) all play a role in determining impedance, heat perception, and total deposited energy despite otherwise equal parameters Temperature also influences tissue conductivity and the distribution of electrical current Generally, every 1°C increase in temperature lowers the skin impedance by 2% Surface cooling will increase resistance to the 300 Lasers in Dermatological Practice electrical field near the epidermis, driving the radiofrequency current into the tissue and increasing the penetration depth In addition, target structures that have been pre-warmed with optical energy will, in theory, have greater conductivity, less resistance, and greater selective heating by the radiofrequency current This is the advantage of hybrid skin-tightening devices that use a combined approach of light and radiofrequency energy together giving synergistic results Monopolar Devices Monopolar devices may be delivered in a static or stamped mode in which a short 1- to 2-second cycle is delivered while the handpiece is held in place (Thermage, Solta Medical, Hayward, CA) Alternatively, monopolar RF may be delivered in a dynamic or a continuous pulse with constant rotation of the handpiece (Exilis, BTL, Prague, Czech Republic) In the static, stamped method, a single pulse is delivered; the handpiece is then moved to an adjacent marked area and fired again This technique is performed for hundreds of pulses until a premarked area is treated Each pulse is measured for temperature while spray cooling is applied so that a skin temperature of 45o C is not exceeded With dynamic monopolar RF, the handpiece is continuously moved and specific areas of laxity can be targeted in a relatively short time to a final temperature that is monitored by continuous surface temperature measurements Thermage It was the first nonsurgical treatment of periorbital skin laxity and rhytides approved by the FDA and has since become a common technique for treating aging skin (mid-face, cheeks, jaw line, neck, brows, abdomen, legs, and thighs) Thermage has been backed by a strong research and development; and now in its third generation, it has evolved into an extremely sophisticated device The first generation device, was called thermacool NXT device which employed 400, 600 and 900 REP (Radiofrequency Energy Pulse) disposable tips with a heat and cooling sensation The next level is the Thermage CPT, which has some features that make it superior to the previous NXT (Figs 8.2A and B) Redesigned tip, which improves uniformity of heating and increases the total area of skin being effectively heated Comfort software intended to simulate transcutaneous electrical nerve stimulation (TENS) pain reduction therapy The TENS therapy for pain management is based on the principle that when electrical current is delivered through the skin, electricity stimulates nerves in the affected Nonsurgical Tightening 301 Fig 8.2A: Overview of the ‘Thermage’ device Fig 8.2B: A closer look at the components of ‘Thermage’ area and sends signals to the brain that scramble normal pain perception In effect, the pulsed behavior of the radiofrequency interwoven with cooling bursts improves patient comfort Vibration based on the gate control theory of pain mitigation The new thermage CPT handpiece vibrates the tips in order to mitigate discomfort This Thermage solution here is based on the gate theory by Melzack and Wall, which states that nerve fibers carrying pain to the spinal cord can have their input modified at the spinal cord before transmission to the brain, in this case by the vibration 302 Lasers in Dermatological Practice CPT (Comfort Pulse Technology) system came with features that maximized thermal distribution and patient comfort both thereby giving better tightening and contouring (Fig 8.2C) The third generation thermage employs the same vibration delivery module but with the new total tip which has even more homogeneous three-dimensional skin tightening These variously sized tips depend mostly on the anatomical area being treated, as larger tips cover a larger area of skin For example, a 1.5 cm tip should be sufficient for the treatment of the face and neck Mechanism of Tissue Heating The mechanism of tissue heating through the use of monopolar radiofrequency in thermage is unique (Fig 8.3) As in conventional RF devices, the tissue heat is generated based on the tissue’s natural resistance to the movement of ions with the RF field but the difference lies in the method of coupling the RF to the skin In thermage, a capacitive coupling membrane is used, which transforms RF to a volumetric tissue heating device rather than a single point heating source as in standard RF devices This allows energy to be distributed over a three-dimensional volume of dermal tissue while protecting the epidermis (Fig 8.4) The use of capacitive rather than conductive coupling is important because it allows the energy to be dispersed across a surface to create a zone of tissue heating With conductive coupling, the energy is concentrated at the tip of the electrode, resulting in increased heating at the contact surface and an increased risk of epidermal injury Fig 8.2C: A comparison of third generation RF with the conventional RF Nonsurgical Tightening 303 Fig 8.3: A depiction of the depth of penetration of ‘Thermage’ Fig 8.4: Difference in the heat generation of ‘Thermage’ and other RF machines Thermage heats tissue more deeply and to higher temperatures than other technologies Temperatures are higher by 3–4° and deep heating means that the heat dwells longer in the tissue The treatment protocol involves marking square grids on the area to be treated so that the requisite amount of overlap be done to ensure complete coverage The tip delivers monopolar radiofrequency to the lower layers of the skin while protecting the epidermis with cryogenic cooling With the new total tip technology, thermage tightens and smoothens close to the surface and contours deeply (Figs 8.5A and B) Although, delivering higher energies translates to better results, it is not meant to be an extremely painful or uncomfortable treatment, especially since pain threshold is relative One may be extremely comfortable with a treatment energy of 4.5 while another may be uncomfortable with an energy 542 Lasers in Dermatological Practice Solta Medical (http://www www.solta.com) 230, 296t, 300, 343t Sunetics International (http://www.sunetics.com) 399 TruSculpt (http://www.trusculpt.com) 296t Ulthera (http://www.ultherapy.com) 294, 322, 333, 377t UltraShapeLtd (http://www.syneron-candela.com/int/product/ultrashape) 321, 331, 348, Venus Freeze (http://www.venusconcept.com) 297t Viora (http://www.viorareaction.com) 297t, Zeltiq Aesthetics (http://www.coolsculpting.com) 356 Index Page numbers followed by f refer to figure and t refer to table A Ablative fractional CO2 laser 367 Ablative fractional resurfacing (AFR) 23, 177, 367 fractional carbon dioxide lasers 177 deka system 183 Lumenis superPulse 178 179f Lumenis ultraPulse,178, 179f solta device 177 fractional erbium:YAG lasers 177, 183 Alma’s fractional 183 fractional erbium:YSGG laser 184 Palomar’s fractional 183 Sciton 183 in hypertrophic scars 367 Ablative lasers 368, 422 absorption spectrum of 26 and fractional lasers, comparison of 173t, 173f excisional surgery/debridement, hair transplants 83 keloids 83 nail matrixectomy 82f in acne keloidalis nuchae 63 in actinic cheilitis 64 in atrophic scars 368 in balanitis xerotica obliterans 85 in benign tumors 71, 72, 73 in chondrodermatitis nodularis helices 85 in compound nevi 71 in dermal nevi 71 in epidermal nevi 67, 93f in excisional surgery/debridement 81 in genital lichen planus 85 in granuloma faciale 85 in keratoderma 85 in kraurosis vulvae 85 in lichen sclerosis et atrophicus 85 in lupus erythematosus 85 in lymphangioma circumscriptum 84 in melanocytic nevi 70 in nevus sebaceous 70 in oral florid papiliomatosis 85 in porokeratosis 85 in psoriasis 85 in pyogenic granuloma 84, 84f indications of 39, 60 limitations of 47 scars 60 acne/chickenpox 60 post-traumatic and surgical 62 ultraPulse lasers 75 vitiligo surgery 84 warts 77 condylomata 79 periungual 79 plantar 78, 80 Zoon’s balanitis 85 Acetaminophen 243 Acne 40, 379 Acne scars 91, 204, 209, 210t, 211t, 214t, 433 boxcar scars 207 controversies and new aspects 477 ice pick scars 206 rolling scars 204 Acne therapy 489 Acoustic waves 357 indications 357 used for local fat deposits 357 544 Lasers in Dermatological Practice Acquired bilateral nevus of Ota like macules (ABNOM) 156 Acquired melanocytic nevi 136 role of various lasers in 140 Activin 399 Adenoma sebaceum 71, 72 Adipocyte 341, 342 Alexandrite laser 10, 20 Alleviate chronic folliculitis 222 Alma device 344 Alopecia areata 227, 399 Alpha-hydroxy acid lotions 109 Aluma 311 Amateur tattoo 113 Aminolevulinic acid (ALA) 271 Anesthetic creams 262 Angiokeratomas of Fordyce 407 long-pulsed Nd:YAG lasers 407 pulsed dye laser 407 Angiolymphoid hyperplasia with eosinophilia 384, 385 copper vapor laser 385 Arbitration 452 Arbutin 152 Argon laser 236, 238, 241 Arolling scars 204 Arrhenius 15 Asodilation 35 Aspect ratio and depth 476 Atrichoepitheliomas 71, 75 Atrophic scars 362, 367 Autoimmune connective tissue disorders 261 Aversian response 497 Axillary hyperhidrosis 487 B Basal cell carcinoma/squamous cell carcinoma 410 ablative lasers 410 Nd:YAG 410 PDT and similar approaches 410 Becker’s nevus 108, 135, 135f Er:YAG laser 135 QS Nd:YAG laser 135 QS ruby laser 135 Bipolar radiofrequency 280, 343, 344 devices 278 Body contouring, devices 336 persistent erythema in 337 pulmonary embolism in 337 thrombophlebitis in 337 Body mass index 342 Boxcar scars 207 C Café au lait macules, 133 QS alexandrite lasers in 133 QS Nd:YAG in 133 QS ruby in 133 Café au lait patches 108 CALM 109, 112f , 137, 138 Carbon 12 Carbon dioxide lasers 25, 30, 63, 86, 105 comparison of 27, 29 comparison with Er:YAG lasers 36, 37f continuous-wave type 25 Cw repeat mode 53, 53f end points 46 minimum thermal damage in 53f paintbrush technique 94f, 96f postoperative care 87, 95f preoperative regimen 86 principles of 26 simple rules 32 superPulse type 27 technique tips 30 thermal diffusion in 26 types of 27 types tissue damage in 26 UltraPulse mode 52, 53f UltraPulse type 26, 28 Cellulaze 350 Cellulite 337 simple scoring system 339 treatment focused ultrasound 339 methylxanthines 339 nonablative laser devices 339 retinol 339 therapeutic modalities 340t Chickenpox scars 40 Chromophore 12, 14, 17, 21, 101 absorption spectra 12f, 22 Index 545 fat 12 hemoglobin 4, 12 melanin penetration 12f water Civil and criminal negligence 444 CO2 10,600 nm 138 CO2 laser and Erb:YAG laser comparison 435t Cobb syndrome 239 Collagen 13 contraction 87 remodeling 204 Collagenesis 282 Colloid milium 227 Combination laser therapy 126 Combination therapy 147t Combination therapy with TC creams 148t Combined-mode erbium YAG/CO2 laser system 368 Complications and their management 455 Concomitant therapy 127 Congenital dermal melanocytosis 156 Q-switched alexandrite laser in 156 Congenital melanocytic nevi 141 ablative lasers with pigment lasers in 141 pigment laser in 141 surgical excision followed by Er:YAG in 141 Corticosteroids 109, 366 Cutting mode 58 Cryosurgery 65, 66 Cryotherapy 236 Cw CO2 17, 69 ultrapulse, comparison 29 Cw laser 64 Cynosure 350 D Damage 446 Darier disease 385 carbon dioxide laser 385 combination of Er:YAG and CO2 386 Debulking surgery 248 Defocused mode 54 In exophytic lesions 54 in rhinophyma 55 in warts 54, 55 Deoxyribonucleic acid 12 Dereliction of duty 446 Dermabrasion 65 Dermal collagen fibers 36 Dermal heating 38 Dermal laser 106, 107 Dermal remodeling 276 Dermal tumour ablation 35 Dermatomyositis 386 argon lasers in 386 pulsed dye lasers in 386 Desmoglein 399 Diode lasers 12 Dirt tattoo 113 Direct causation 446 Disseminated granuloma annulare 227 Drug-induced hyperpigmentation 158 Dye lasers 5, 12 Dyschromias 222, 286 Dyspigmentation 41 E Eczema 386 PDL in 386 Elastinogenesis 282 Elastosis perforans serpiginosa 386 Er:YAG laser in 386 pulsed carbon dioxide in 386 Electromagnetic spectrum 34 Electrosurgery 65 ELOS 312 eMatrix 312 Endogenous porphyrins 379 Ephelides 134 Epidermal disorders 131 IPL 132 lasers used in 132 lentigines in 131 milisecond devices in 132 Qsw devices in 132 Epidermal growth factor (EGF) 399 Epidermal laser 106, 107, 108t 546 Lasers in Dermatological Practice Epidermal nevi 436 Epithelioma adenoides cysticum 381 Er:YAG 2940 nm 138 Erbium laser 432 lower depth of ablation 432 thermal damage 432 Erbium peel 41 Erbium:doped yttrium-aluminiumgarnet (Er:YAG) laser 16 Erbium:glass laser 6, 11, 17, 22, 32, 47, 62, 73, 78, 88 1535 nm 175 1540 nm 175 1550 nm 175 in acne scar 211t, 214t Erbium:YAG laser 6, 11, 17, 22, 32, 47, 62, 73, 78, 88, 105, 368, 381, 383, 418 combination of 37 conventional 33 Gaussian laser beam profile 34 in junctional nevi 39 in sebaceous hyperplasia 39 in seborrheic keratoses 39 in solar keratoses 39 in trichoepithelioma 39 intraoperative dose/depth 90 intraoperative end point 90 intraoperative postoperative care 91, 99f, 100f junctional nevi 39 modulated 33 postoperative care 91, 99f, 100f pretreatment regimen 89 sebaceous hyperplasia 39 seborrheic keratoses 39 solar keratoses 39 treatment guidelines for 49 trichoepithelioma 39 Erbium:yttrium-scandium-galliumgarnet (YSGG) 105, 177, 178f Erythroplasia of Queyrat/Bowen’s disease 410, 411f fluorouracil in 411 imiquimod 411 PDT 411 pulsed CO2 Laser in 411 Eutectic mixture of local anesthetic (EMLA) 534 absorption and distribution 534 adverse effects 536 allergic contact dermatitis 536 petechia 536 methemoglobinemia 537 usage guidelines 535 Excimer laser 423 Excimer laser indications 395 halo nevus 395 hypopigmented striae 395 nevus depigmentosus 395 postresurfacing leukoderma 395 Eye safety 496, 498 Eyelid laxity 286 F Faces 311 Facial telangiectasia 241 Far infrared systems 11 Fibroblast growth factor 399 Fibrous papule of nose 381 Fitzpatrick skin type 261, 329 Fitzpatrick wrinkle classification system 316 Flashlamp-pumped pulsed dye lasers 237 Flavin 12 Fluence 32, 32f, 89, 255 in hair removal laser 255 Fluorescent lamps Fluorescent pulse light 258 Folliculitis 367 Fractional ablative lasers 275 Fractional ablative radiotherapy 184 Fractional devices 488 Fractional laser 180t-182t, 366, 370, 418, 422, 522 complications of 478 controversies and new aspects 476 in acne scars 204, 205t boxcar scars 207, 207f ice pick scars 205f, 206 rolling scars 204, 205f, 206f in actinic keratoses 223 in atrophic scars 370 in Beckers nevus 226 in lichen amyloidosis 226 in melasma 224 in nevus of Ota 226 Index 547 in non-acne scars 220 in photodamage skin 217, 219f in poikiloderma of civatte 227 in post-acne scarring 204 in post-inflammatory hyperpigmentation 226 in rhytides 220 in striae 223 indications 193, 194t minocycline pigmentation 226 Fractional photothermolysis 172, 366 collagen remodeling in 172 elastic tissue formation in 172 intraoperative 195, 230 intraoperative scanning hand piece 195, 196f, 230 intraoperative stamping hand piece 197, 230 patient selection 229 anxiety level 229 herpes simplex infection 229 isotretinoin use 194, 229 keloids 229 lidocaine allergy 229 pain tolerance 229 postinflammatory hyperpigmentation 229 postoperative management 198, 231 preoperative steps 194, 229 anesthesia 230 antiviral prophylaxis 194, 230 baseline photograph 230 sunscreens 229 rapid healing in 174, 174f Fractional thulium laser 185 Freckles 108t, 113, 134, 436 Frequency-doubled QS Nd:YAG lasers 133 Fresnel reflectance G Gas lasers Gate theory by Melzack and Wall 301 Glomus 407 pulsed dye laser in 407 Grafting 236 Granuloma annulare 386 PDL in 386 Granuloma faciale 387 argon laser in 387 Green yellow (GY) wavelengths 10 H Hailey-Hailey disease 286, 387 carbon dioxide laser in 387 Er:YAG 2,940-nm laser in 387 Hair growth devices 489 Hair reduction lasers 417 alexandrite-755 nm 417 diode-810 nm 417 IPL-400–1200 nm 417 IPL-590–1,200 nm 418 LP Nd:YAG-1064 nm 417 QS alexandrite laser-755 nm 418 QS frequency doubled Nd:YAG laser-532 nm 418 QS Nd:YAG laser-1,064 nm 418 QS ruby laser-694 nm 418 Hair removal 514 Hair removal devices 258, 259, 489 475 to 1,200 nm IPL Silk’n device 259 810-nm diode Tria laser 259 diode combined with RF 258 intense pulsed light (IPL) system (515–1,200 nm) 258 long-pulsed alexandrite laser (755 nm) 258 Nd:YAG laser (1,064 nm) 258 ruby laser 258 semiconductor diode laser (800–810 nm) 258 optical light energy combined with RF 258 Hair removal laser 252–272, 423, 438 cooling mechanism in 256 chill tip cooling 256 cryogen sprays 256 forced refrigerated air 256 ice packs 256 Hair types 253 terminal 253 vellus 253 Halogen lamps 11 548 Lasers in Dermatological Practice Hemangioma 246, 279 KTP 248 long-pulse PDL in 248 Nd:YAG 1,064 laser in 248 Hemostasis 32, 64 Hidrocystomas 71 High intensity focused ultrasound (HIFU) 346 1440 nm lasers 350 635 nm laser 350 advantages 354 diode lasers 349 LipoSonixTM 348 preoperative workup 352 procedure 351 smoothshapes 350 techniques 352 ultrashape 346 with Nd:YAG laser 349 Highly pigment selective lasers 105 Hirsutism 254 Histological depth 476 Home use devices 258, 488 Hori’s macules see ABNOM HPV infection 80 Human papilloma virus 77 Hybrid monopolar and bipolar radiofrequency 313 Hydroquinone 109 Hyperemia 222 Hyperthermia 14 Hypertrichosis 254 Hypertrophic scars 361 I Ice pick scars 206 IFUS in body contouring 331 in tissue laxity management 330 Infantile hemangioma 239 bleeding in 240 deep 240 infection in 240 mixed 240 superficial 240 ulceration in 240 Infraorbital hyperpigmentation 108, 157 Infrared laser 277, 283 1,064 nm Nd:YAG 283 1,450 nm diode acne 284 1,450 nm mid-infrared diode laser 283 fine lines 283 in acne scars on face 283 in acne vulgaris 283 in wrinkles 283 1,540 nm erbium: glass(NAFR) 284 in melasma 285 in perioral and periorbital rhytids 285 in periorbital rhytides 285 in pigmented lesions 285 in scarring 285 in skin resurfacing 285 1,540 nm Erbium:glass 283 infrared laser-1,320 nm Nd:YAG 284 in acne scarring 284 in photodamage 284 infrared laser-1,550 nm erbium-doped fiber 285 Infrared light devices 314 Infrared radiation 497 Infrared wavelength lasers 380 Ingrowing toe nail 81 Intense focused ultrasound 185, 319 Intense pulsed light 275, 280, 367, 483 devices 241, 278 in pigmentation 280 in vascular lesions 280 Interrupted radiation Invisible light lasers 277 Isotretinoin 194 K Keloids 361, 362, 436 Kirby Desai scale 119 Kirby Desai score 116, 161 Klippel-Trenaunay syndrome 239 Koenen tumors 381 Kojic acid 152 KTP lasers 275, 279 Index 549 L Labial melanotic macules 133 Labile psoriasis 88 Large lipomas 487 Laser and melanocyte grafting 396 Laser beam profiles Gaussian or bell-shaped 8, 9f top hat beam 8f Laser clinic 416 private setup 416 public funded 421 FDA 510(K) clearances 426 laser procurement 424 regulatory approval 425 Laser complications 455, 456 crusting and vesiculation 458 dyspigmentation/post-inflammatory hyperpigmentation 460 erythema and edema 457 fractional lasers 463 post-inflammatory hyperpigmentation 464 hair removal lasers 464 burns 465 hypertrichosis 464 leukotrichia 464 pigmentary alterations 467 pigmented lesions laser 466 reticulate erythema 465 tissue splatter and pinpoint bleeding 466 urticarial-like plaques 465 hypopigmentation 461 lasers for pigmented lesions leukotrichia 468 tissue splatter 466 pigmentary alterations 467 pinpoint bleeding 466 pain 456 purpura 459 scarring 462 vascular lesions 468 reticulated purpura 468 Laser for acute wounds 408 Laser for chronic wounds 409 Laser for inducing leukoderma 396 monobenzylether of hydroquinone 396 Q-switched alexandrite laser 397 Q-switched ruby 397 Laser hair reduction consent form in 260 contraindications of 257 herpes labialis 257 staphylococcal infection 257 superficial cuts and injuries 258 systemic lupus erythematosus 257 drugs used in 261 eflornithine role 268, 271 for gray hair 269 hair color in 261 indications of 257, 257f marking of area in 262 pseudofolliculitis in 269 results of 260 long-term efficacy 260 short-term efficacy 260 test patch in 262 topical anesthetics in 262 Laser lipolysis 341, 349, 423 Laser penetration depth of 22 Laser safety standards 499 Laser surgery complications 439 hypopigmentation 439 postinflammatory hyperpigmentation 439 Laser therapy for scars 363 Laser tissue interaction 13 Law of Snellius 12 Leal laxity classification system 316 Leds 275, 278 590 nm nonthermal full-face leds 282 633 nm leds therapy 281 combination therapy with 830 nm and 633 nm 281 Lentigines 108t, 276 Lesional darkening 161 Lesions geometry 21 Less pigment selective laser 105 Levofloxacin 42 LHR dark skin types 270 electrical safety 268 eye protection in 263, 268 fire protection in 268 in pregnant women 271 550 Lasers in Dermatological Practice post-procedure care 263 side effects 265 crusting 265 deep burn 266 hyperpigmentation 265 hypopigmentation 265 mild burning 265 paradoxical hair stimulation 266, 267f perifollicular erythema 265 permanent scarring 265 persistent erythema 265 superficial burns 266 thermal burns 265 transient erythema post-session 265 vesiculation 265 Lichen sclerosus 387 carbon dioxide in 388 clotebatosol propionate in 387 Lidocaine 528 absorption and distribution 528, 532 adverse effects 530, 533 allergic reactions 531 clinical use in dermatology 533 CNS toxicity 530 CVS toxicity 531 mechanism of action 528, 532 usage guidelines 533 Light-based devices and laser-assisted lipolysis 349 Light-emitting diodes (LED) 281 Linear porokeratosis 286 Long pulse 1,064 nm Nd:YAG 294 Low power 410 nm led Low-level laser therapy (LLLT) 399, 400 alopecia 401t hair laser 399 HairMax LaserComb 399 in alopecia 399 laser hair brush and clinical unit 399 photobiostimulation 400 LPG systems 343 Lumenis SuperPulse CO2 179f UltraPulse CO2 179f Lupus erythematosus 388 PDL 388 Lupus pernio 390 532-nm frequency-doubled Nd:YAG laser 390 carbon dioxide laser 390 M Macrowound 186 Malpractice claims 448 Matted telangiectasias 227 Medical negligence 445 Medicolegal aspects of lasers in dermatological practice 441 Melanin 12, 17, 101, 102f, 254, 269, 277 in hair removal laser 254 invisible light lasers 277 Melanized keratinocytes 105 Melanocytes 105 Melanocytic nevus 436 Melasma 108, 142, 225 controversies and new aspects 474 Er:YAG 144 fractional lasers 143 pigment specific 142 Microfocused ultrasound 322, 327, 333 Microsecond lasers Microthermal zone (MTZ) 172, 174, 175 190-193 Mid-infrared lasers 11 Minimally ablative lasers 275 Minocycline pigmentation 158 Modulated Er:YAG 67 Moles 108 Molluscum contagiosum 384 adapalene in 384 cantharidin in 384 cryosurgery in 384 curettage in 384 flashlamp-pumped pulsed dye laser 384 fluorouracil 384 salicylic acid in 384 topical imiquimod 384 tretinoin in 384 Monopolar RF 278 Monotherapy 146t Mycosis fungoides 413 Myxoid cysts 71 Index 551 N NAFR (1,550 nm Erbium-doped fiber laser) 366 Narrowband UVB 391, 394 Nd:YAG laser 13, 16, 17, 20, 22, 138, 279 1,064 nm 10, 279 1320 nm 175 1410 nm 175 1440 nm 175 Necrobiosis lipoidica 389 PDL 389 photodynamic therapy 389 Neodymium:yttrium-aluminum garnet 138, 237, 383, 532 Neurofibromas 71, 72, 381 Neurotoxins 220 Nevi, epidermal and dermal 67 Nevocellular nevus 106 Nevus comedonicus 68 Nevus of Ota 109, 152 combination of QS Nd:YAG-1 in 153 controversies and new aspects 474 fractional laser in 153 laser result in 153, 154t Qsw lasers in 152 scanned CO2 with Qsw laser in 152 Nevus Spilus 108, 109, 133 Nodular amyloidosis 389 PDL 389 Nominal hazard zone 493, 499 Nonablative fractional laser and fractional ablative lasers comparison 478 rejuvenation (NAFR) 275 resurfacing (NAFR) 175, 175f Nonablative lasers 369 1,064 nm Q-switched Nd:YAG laser 369 1,320 Nd:YAG laser 369 1,450 nm diode laser 369 1,540-nm erbium-doped phosphate glass laser 369 585 nm PDL and intense pulse light system 369 in atrophic scars 369 Non-invasive body contouring 342 contraindications 342 treatment devices 342 radiofrequency energy devices 343 suction/massage devices 342 Nonsurgical sculpting 358, 484 issues and controversies 358 Nova-pulse 28 Novel wavelengths 479, 486 Novus actus interveniens 447 Nuclear acids 12 O Onychomycosis 403, 405t Operational modes Optical spectrum Oral retinoid therapy 41 Organic dye 237 Oxyhemoglobin 237, 254, 383, 388 in hair removal laser 254 in vascular lesion 237 P Paget’s disease 412 pulsed CO2 laser in 412 Pain free lasers 271 Paint-brush motion 177 Parapsoriasis 413 Patient information sheet 514, 521 Pattern alopecia 227 PDL 364, 374 acne scars 364 edema of 366 facial scars resulting from cutaneous surgery 364 hyperpigmentation 366 in hypertrophic scars and keloids 364 purpura 366 skin 366 sternotomy scars 364 Pearly penile papules 72, 227 PEODN 68, 68f Permanent hair reduction 252 FDA’s definition 252 Photoaged skin 286 Photodamaged skin 283 classification of 276t laser use 289 552 Lasers in Dermatological Practice Photodisruption 16 Photodynamic therapy (PDT) 271, 380 P acnes 380 photodestruction of 380 photodestruction of sebaceous glands in 380 Photothermal destruction 254 in hair removal laser 254 Photothermal reactions 14 Photothermolysis 126 Pigment nonselective lasers 105 Pigment selective laser 103, 103f, 105, 106, 116, 137 in selective disorders 108t Pigmented lesions laser 472 Pigmented lesions/tattoos dose/method 110 end points 161 intraoperative steps 161 patient information sheet 517 postoperative steps 161 preoperative steps 160 anesthesia 160 baseline photograph 160 biopsy 160 eye safety 161 pretreatment preparation 109 steps of therapy 109, 110t subsequent sittings 112 treatment prerequisites 109 Pinpoint bleeding 90, 91 Plantar warts 31 Plasma skin regeneration 38 Pneumatic skin flattening (PSF) 271 Pockel cell Poikiloderma of civatte 241 Polycystic ovarian disease (PCOD) 261, 269 Popsicle panniculitis 355 Porphyrin 12 Portrait plasma skin regeneration 279 Portrait PSR 285 contraindications 286 dose 286 Port-wine stains 236, 239, 244, 279, 388, 483 argon laser in 245 PDL 244 PDL adverse events in discoloration 245 epidermal crusting 245 hypertrophic scarring 245 hypopigmentation 245 keloid formation 245 purpura 245 post-capillary venules involvement 239 segmental 239 Post-inflammatory hyperpigmentation 151 fractional lasers 151 vascular lasers 151 Post-inflammatory hypopigmentation 227 Post-traumatic 220 Potassium titanyl phosphate (KTP) 241 Power density Practical laser therapy indications 193, 194t intraoperative procedure 195 method of use 195 autofill scan mode 196 dose 197 interlaced 196 normal mode 196 scanning mode 195 sittings 198 post-operative instructions 198 antibiotic medication 199 anti-inflammatory medication 199 preoperative evaluation prophylactic antibiotic 194 antiviral 194 side effects 199 bronzing 199 edema 199 flaking 199 postoperative discomfort 199 sunburn like erythema 199 sunburn sensation 199 Prescars 362, 372 in 585 nm PDL system 372 in Er:YAG laser 372 Prilocaine 532 Principles of laser therapy for scars 371 Procollagen production 278 Index 553 Propionibacterium acnes 379 Proteus syndrome 239 Psoralen plus UVA 391 Psoriasis 390 PUVA/SOL 390 ultraviolet B phototherapy 391 Pulse carbon dioxide 432 thermal relaxation time 432 Pulse duration 255 in fractional laser treatment 187 in hair removal laser 255 Pulsed CO2 lasers 21, 39 in zoons balanitis 39 used in dermal disorders 39 Pulsed CO2, treatment guidelines for 49 Pulsed dye laser (PDL) 138, 241, 279, 367 Pulsed dye, Q-switched (Qsw) 138 Pulsed Er:YAG laser 66 Pulsed MIR lasers 16 Q QS 1064 nm Nd:YAG laser 156 comparison of 138 QS 532-nm Nd:YAG laser, combination of 156 QS ruby lasers 133 Qsw lasers 8, 20, 101,157 ablative lasers 157 fractional lasers YSGG 2,790 nm 157 Q-switched alexandrite laser 105, 133 157 Nd:YAG comparison 138 Q-switched lasers Q-switched Nd:YAG laser 105, 158 Q-switched neodymium 105 Q-switched ruby laser 105, 383 R R20R technique 125 Radiofrequency 295–297 bipolar 295 combination devices 295 polaris WR systems 295 current-based devices 319 monopolar RF collagen contraction 298 immediate skin tightening in 298 multipolar 295 patient information sheet 524 principles of RF 295 unipolar RF 295 Recalcitrant disseminated superficial actinic porokeratosis 227 Recalcitrant tattoos, lasers and modifications used 128 Red and near IR wavelengths 10 Refirme ST system 312 Repeat mode 55 Residual thermal damage (RTD) 34, 56 lentigos 56 photodamage 56 Resurfacing mode 52 Resurfacing techniques circular 43 end points 44 paintbrush 44 single spot 44 types of 43 ResurFx module 479 Retinol 12 RF monopolar devices 300 bipolar RF 309 disadvantage 311 exilis elite device 309 multiple variations of 309 thermage 300 abdomen 305 anesthesia 305 back of hands 305 coupling fluid 305 CPT (comfort pulse technology) 302 exclusion criterion 304 hooding of eyelids 305 improve skin tone 308 improved jawline contouring 306 in acne 308 in cellulite 308 in periorbital skin laxity 300 in rhytides 300 jawline 305 lifting of eyelids 307 554 Lasers in Dermatological Practice marking square grids 303 relative contradiction 305 side effects 306 smoothing 308 softening of wrinkles 307 suitable candidates 304 tens therapy 300 Thermacool NXT device 300 thighs 305 tightening of skin 308 Rhytides 91, 286 Ribonucleic acid (RNA) 12 Rolling technique 189, 190 Rosacea 240 erythematotelangiectatic 240 ocular 240 papulopustular 240 phymatous 240 staging 240 telangiectasias 388 PDL 388 S Sarcoidosis 389 Scar sarcoidosis 390 Q-switched ruby laser in 390 Scars 40, 361 Sebaceous hyperplasia 71, 74 Seborrheic keratoses 73, 97f, 134, 286, 383 Er:YAG 134 pulsed CO2 lasers 134 Selective cryolipolysis 355, 356 Selective photothermolysis 17, 26, 254 and laser assisted hair removal 20 fractional photothermolysis difference 174, 174t in hair removal laser 254 of cutaneous blood vessels 20 of pigmented lesions 20 of tattoos 19 theory 236 Selectine potothermostimulation 487 Sharplan SilkLaser 28 Skin cooling 256 in hair removal laser 256 Skin tightening devices 294t Soe syndrome 288 Solid-state lasers Spider hemangiomas 407 high-powered 532-nm device 407 PDL 407 Spot 113 diameter 21 laser resurfacing 63 size 35, 89, 124, 256 in hair removal laser 256 in Qsw laser 125f Stamped scanning technology 177 Stamping technique 189, 190f Steatocystomas 74 Stress confinement 15 Stretch marks 361 Striae distensae 373, 481 1,064 nm Nd:YAG laser 374 308-nm excimer laser 374 flash-pumped 585 nm pulse dye laser 374 intense pulsed light 374 nonablative 1,450 nm diode laser 374 nonablative fractional CO2 resurfacing 374 radiofrequency device 374 Sturge-Weber syndrome 239 Subablative pulses 35 multiple 35 Subsurface lasers 275, 423 Superficial dermal plexus 35 Superficial skin lesions 286 Supertumescence 358 Surgical scars 220 Syringocystadenoma papilliferum 71 Syringomas 35, 71, 73, 98f System, of Richard Glogau 276 T T mentagrophytes 404 T rubrum 403 Tattoo 115, 436, 472 Tattoo dependent factors age 122 amateur 120 color 121 ideal interval 125 Index 555 ideal technique 126 location 122 non-responsive tattoo ink 124 paradoxical ink darkening 123 professional 120 pulse duration 126 scar/granuloma 123 sessions 126 skin type 123 undesired pigmentary alteration 124 Tattoo pigments 115 absorption spectrum 118f laser induced resolution 118, 119 laser used for removal 118t, 122t Tattoo removal 119 paradoxical ink darkening 123 patient-dependent factors 119, 120, 123 scar/granuloma 123 skin type 123 tattoo-dependent factors 120 Tattoo types 117t traumatic 117t amateur 117t cosmetic 117t iatrogenic 117t medicinal 117t professional 117t Telangiectasia 249, 276, 407 apider 249 arborizing 249 papular 249 PDL in 249, 407 simple or linear 249 Telogen effluvium 399 Thermal coagulation points (TCP) 322 Thermal confinement 15 Thermal damage 15, 20, 28, 30, 35 Thermal diffusion 15 in radiofrequency 299 monopolar rf type I collagen 299 Thermal injury 32 Thermal necrosis 32 Thermal relaxation time (TRT) 17, 18, 36 Thermal zone 322 Tissue ablation 15 Titanium sapphire laser 16 TriactiveTM 343 Trichoepithelioma 381 Trichoscan images 262 Tumescent liposuction using suction cannulas 337 Typical complications of laser 442t U Ulthera 322, 325 UltraPulse CO2 and superPulse CO2 comparison 478 UltraPulse or Er:YAG laser 76 Ultrashort laser pulses Ultrasound-assisted liposuction (UAL) 320 Ultrasound devices 315 Unipolar RF devices 345 tripolar radiofrequency 346 Freezetm 346 Titefxtm 346 Tripollartm 346 UV laser 9, 16 in inflammatory skin diseases in vitiligo UV light 497 V Vaporization mode 54 Varicose veins 241 Vascular laser therapy intraoperative 242 patient selection 242 postoperative 243 blister and/or crust formation 243 topical steroid-antibiotic cream usage 243 preoperative 242 lignocaine 242 prilocaine 242 Vascular laser 278, 422, 483 intense pulsed light (IPL) 238 port-wine stain 239 absence of perivascular nervous tissue 239 diffuse 239 extensive 239 556 Lasers in Dermatological Practice Venous lakes 241, 408 755-nm alexandrite lasers 408 combined 595-nm/1,064-nm multiplex device 408 long-pulse Nd:YAG lasers 408 PDLS 408 Vicarious liability 443 Violet IPL emissions Viral diseases 41 Viral disorders 383 CO2 laser light in 383 FPDL 383 lasers used 383 Viral papillomata 286 Viral warts 384 FPDL treatment blistering 384 post-lesional hyperpigmentation 384 scarring 384 Visible light lasers 277 Vitiligo 88, 393 308-nm excimer laser in 394 632.8-nm helium-neon laser in 394 Vulvar lichen sclerosus 388 W Water, infrared lasers 277 Wavelength 255 in fractional laser treatment 187 in hair removal laser 255 Wound healing 408 Wrinkles 41 X Xanthelasma 71, 75, 77f Z Zoon’s balanitis 409 ... fibers carrying pain to the spinal cord can have their input modified at the spinal cord before transmission to the brain, in this case by the vibration 3 02 Lasers in Dermatological Practice CPT... laser compared Lasers in Surgery and Medicine 20 07 ;2: 16-75 12 Lolis MS, Goldberg DJ Radiofrequency in cosmetic dermatology: a review Dermatol Surg 20 12; 38(11):1765-76 13 Narins DJ, Narins RS Non–surgical... Dermatol 20 06;5(8):707- 12 21 Yu CS, Yeung CK, Shek SY, et al Combined infrared light and bipolar radiofrequency for skin tightening in Asians Lasers Surg Med 20 07;39:471-5 22 Zelickson B, Ross V,